This Month in Anesthesiology

This document updates the Practice Guidelines for patients with chronic noncancer neuropathic, somatic, or visceral pain syndromes.

The history of the use of biomarkers to increase the rate of perioperative myocardial infarction detection is reviewed.

Incremental decreases of intraoperative glucose concentrations did not consistently reduce risk.

Adverse effects of residual paralysis after emergence from anesthesia are reviewed.

The use of simulation for measuring physician skills and competencies is reviewed.

Although many epidemiologic studies have examined sepsis, postoperative sepsis specifically is not as well understood. Using the Nationwide Inpatient Sample, elective admissions of adult patients with a length of stay longer than 3 days for common elective operative procedures were analyzed between 1997 and 2006. Of 2,039,776 admissions identified, the rate of severe sepsis rose from 0.3% to 0.9%. This trend persisted after adjusting for relevant covariables. The in-hospital mortality rate for patients with severe postoperative sepsis declined from 44.4% to 34.0%; this trend also persisted after adjustment for relevant covariables. During the 10-yr period studied, there was an increase in the rate of severe postoperative sepsis, despite a concomitant decrease in the in-hospital mortality rate.

The duration of action of the novel neuromuscular blocking drug, CW002, is dependent on its interactions with exogenous and endogenous cysteines. The current study examined the pharmacodynamics and safety of CW002 in dogs. The ED⁹⁵was 0.009 mg/kg. At 3 × ED⁹⁵, onset time was 2.6 ± 0.9 min and duration 47 ± 9 min. l-cysteine (50 mg/kg) injected 1 min after CW002 shortened the duration to 3.7 ± 0.6 min. At 25 × ED⁹⁵, CW002 reduced mean arterial pressure. Concomitant declines in systemic vascular resistance, mean pulmonary artery pressure, cardiac output, contractility, and lusitropy began at 50 × ED⁹⁵. However, even at a dose of 100 × ED⁹⁵the average change in any variable was less than 20%. CW002 is a potent neuromuscular blocking drug that at doses up to 100 × ED⁹⁵produces modest hemodynamic effects that are not associated with bronchoconstriction or consistent histamine release.

Medication management is an integral part of chronic pain management and its role in anesthesia chronic pain liability is increasing. Malpractice claims for chronic pain were collected from 2005 to 2008 and compared with other chronic pain claims from the American Society of Anesthesiologists Closed Claims Database. Medication management represented 17% of 295 chronic noncancer pain claims. Compared with other chronic pain claims, claims of medication management were more frequent in younger males with back pain. Most patients were prescribed opioids (94%) and additional psychoactive medications (58%), and had at least one factor associated with medication misuse (80%). Death was the most common outcome in medication management claims and was associated with long-acting opioids, additional psychoactive medications, and more than three factors commonly associated with medication misuse. Most anesthesia malpractice claims for medication management problems involved patients with a history of risk behaviors commonly associated with medication misuse. See the accompanying Editorial View on  page 777